NEWS | I N D E P T H
SANITATION
For toilets, money matters New work suggests that subsidies to the poor to buy latrines could help end open defecation By Jocelyn Kaiser
W
hen nature calls, about 1 billion people in the developing world still head to an open field, the bushes, or a body of water to defecate. The practice has contributed to high rates of diarrheal diseases, especially in India, where more than half of people don’t use latrines. Prime Minister Narendra Modi, who took power last May, has pledged to build 111 million toilets as part of the Clean India mission, a sanitation campaign. One goal is to end open defecation by October 2019. But exactly how to get there is surprisingly controversial. Some nongovernmental organizations and government officials in developing countries have long pushed for education campaigns—teaching people about the health benefits of using toilets. Others advocate subsidizing latrine costs for the poor, but some economists argue that financial aid for cheap toilets could backfire by discouraging those who don’t receive it from buying latrines on their own for a higher price. Now, one of the largest controlled experiments to examine sanitation strategies, conducted in India’s neighbor Bangladesh and published online this week in Science (http:// scim.ag/RGuiteras), comes down strongly in favor of cash. After comparing three policies in more than 100 villages, the authors found that the key to getting people to build latrines 272
is to subsidize the cost. They also found that funding poor villagers to install latrines can encourage their unsubsidized neighbors to follow suit in a beneficial spillover effect. “Given the enormous emphasis Prime Minister Modi has placed on eliminating open defecation in India, these results should be of great interest to [the Indian government]. It tells us that cutting the price of quality toilets is the single most powerful instrument in getting people to stop defecating outside,” says economist Abhijit Banerjee of the Massachusetts Institute of Technology in Cambridge, who was not involved in the study. Others caution, however, that building toilets doesn’t always mean people will use them or be healthier, or that findings in Bangladesh will be relevant to culturally different India. The experiment, funded by the Bill & Melinda Gates Foundation in Seattle, Washington, took place in the Tanore, a poor, rural district in northwest Bangladesh. Although open defecation rates are only 3% overall in Bangladesh, in Tanore, about one-third of adults still follow the practice or use unhygienic latrines, such as “hanging” latrines that empty into waterways. Yale University economists Mushfiq Mobarak and James Levinsohn and Raymond Guiteras of the University of Maryland, College Park, chose 107 villages with 18,254 poor households. Some villages received education on the importance of sanitation, and some received only information on buying and installing
a latrine. In a third program, 25% to 75% of villagers received vouchers through a lottery. Each voucher was good for about 50% off the $29 to $58 cost of an installed pour flush latrine—a design that carries feces to a sealed pit. The vouchers made all the difference, the researchers found 13 months later. Education alone or information on how to acquire a latrine did not significantly increase the portion of people who owned or had access to a hygienic latrine. But education plus vouchers resulted in significant change—for example, a rise in hygienic latrine ownership from 22% in the control group to 45% in villages where half the households received vouchers and education. The study also found a reduction of 14% in open defecation in these same villages. The big surprise was that even people who didn’t receive a voucher were more inclined to buy a latrine at full price if their neighbors received vouchers. This effect was stronger when a higher proportion of households received vouchers. People were also more likely to use their vouchers in neighborhoods where more households received vouchers. For policymakers, the message is clear, Mobarak says: “If you are going to use subsidies, it makes sense to allocate them in a coordinated manner so that many people in a community all get subsidies jointly.” Varad Pande, an economist with the Dalberg consulting firm in Mumbai, India, who has advised the Indian government and the World Bank about sanitation policies, says the results “resonate with our experience on the ground. … Both [subsidies and education] need to happen in a well-orchestrated sequence.” To Sumeet Patil, an epidemiologist and economist with the Network for Engineering and Economics Research and Management in Mumbai, the result should settle the debate over toilet subsidies. But others say an encouraging result in Bangladesh may not say much about India, where the hygiene problem is much bigger. A survey released last year by the Research Institute for Compassionate Economics (RICE) in New Delhi found that many Indians who have access to a hygienic latrine still prefer open defecation, particularly Hindus, who were not represented in the Bangladesh study. The reasons may involve Hindu caste system beliefs that allowing feces to accumulate in a latrine is impure and that only an “untouchable” can remove them, says RICE Executive Director Dean Spears. He adds: “I would just say we should be very careful about generalizing [the Science findings] to Hindu rural north India.” ■ sciencemag.org SCIENCE
17 APRIL 2015 • VOL 348 ISSUE 6232
Published by AAAS
PHOTO: © KAREN KASMAUSKI/CORBIS
In Bangladesh, some people still use “hanging latrines” that dump feces into a body of water.
SANITATION
For toilets, money matters New work suggests that subsidies to the poor to buy latrines could help end open defecation By Jocelyn Kaiser
W
hen nature calls, about 1 billion people in the developing world still head to an open field, the bushes, or a body of water to defecate. The practice has contributed to high rates of diarrheal diseases, especially in India, where more than half of people don’t use latrines. Prime Minister Narendra Modi, who took power last May, has pledged to build 111 million toilets as part of the Clean India mission, a sanitation campaign. One goal is to end open defecation by October 2019. But exactly how to get there is surprisingly controversial. Some nongovernmental organizations and government officials in developing countries have long pushed for education campaigns—teaching people about the health benefits of using toilets. Others advocate subsidizing latrine costs for the poor, but some economists argue that financial aid for cheap toilets could backfire by discouraging those who don’t receive it from buying latrines on their own for a higher price. Now, one of the largest controlled experiments to examine sanitation strategies, conducted in India’s neighbor Bangladesh and published online this week in Science (http:// scim.ag/RGuiteras), comes down strongly in favor of cash. After comparing three policies in more than 100 villages, the authors found that the key to getting people to build latrines 272
is to subsidize the cost. They also found that funding poor villagers to install latrines can encourage their unsubsidized neighbors to follow suit in a beneficial spillover effect. “Given the enormous emphasis Prime Minister Modi has placed on eliminating open defecation in India, these results should be of great interest to [the Indian government]. It tells us that cutting the price of quality toilets is the single most powerful instrument in getting people to stop defecating outside,” says economist Abhijit Banerjee of the Massachusetts Institute of Technology in Cambridge, who was not involved in the study. Others caution, however, that building toilets doesn’t always mean people will use them or be healthier, or that findings in Bangladesh will be relevant to culturally different India. The experiment, funded by the Bill & Melinda Gates Foundation in Seattle, Washington, took place in the Tanore, a poor, rural district in northwest Bangladesh. Although open defecation rates are only 3% overall in Bangladesh, in Tanore, about one-third of adults still follow the practice or use unhygienic latrines, such as “hanging” latrines that empty into waterways. Yale University economists Mushfiq Mobarak and James Levinsohn and Raymond Guiteras of the University of Maryland, College Park, chose 107 villages with 18,254 poor households. Some villages received education on the importance of sanitation, and some received only information on buying and installing
a latrine. In a third program, 25% to 75% of villagers received vouchers through a lottery. Each voucher was good for about 50% off the $29 to $58 cost of an installed pour flush latrine—a design that carries feces to a sealed pit. The vouchers made all the difference, the researchers found 13 months later. Education alone or information on how to acquire a latrine did not significantly increase the portion of people who owned or had access to a hygienic latrine. But education plus vouchers resulted in significant change—for example, a rise in hygienic latrine ownership from 22% in the control group to 45% in villages where half the households received vouchers and education. The study also found a reduction of 14% in open defecation in these same villages. The big surprise was that even people who didn’t receive a voucher were more inclined to buy a latrine at full price if their neighbors received vouchers. This effect was stronger when a higher proportion of households received vouchers. People were also more likely to use their vouchers in neighborhoods where more households received vouchers. For policymakers, the message is clear, Mobarak says: “If you are going to use subsidies, it makes sense to allocate them in a coordinated manner so that many people in a community all get subsidies jointly.” Varad Pande, an economist with the Dalberg consulting firm in Mumbai, India, who has advised the Indian government and the World Bank about sanitation policies, says the results “resonate with our experience on the ground. … Both [subsidies and education] need to happen in a well-orchestrated sequence.” To Sumeet Patil, an epidemiologist and economist with the Network for Engineering and Economics Research and Management in Mumbai, the result should settle the debate over toilet subsidies. But others say an encouraging result in Bangladesh may not say much about India, where the hygiene problem is much bigger. A survey released last year by the Research Institute for Compassionate Economics (RICE) in New Delhi found that many Indians who have access to a hygienic latrine still prefer open defecation, particularly Hindus, who were not represented in the Bangladesh study. The reasons may involve Hindu caste system beliefs that allowing feces to accumulate in a latrine is impure and that only an “untouchable” can remove them, says RICE Executive Director Dean Spears. He adds: “I would just say we should be very careful about generalizing [the Science findings] to Hindu rural north India.” ■ sciencemag.org SCIENCE
17 APRIL 2015 • VOL 348 ISSUE 6232
Published by AAAS
PHOTO: © KAREN KASMAUSKI/CORBIS
In Bangladesh, some people still use “hanging latrines” that dump feces into a body of water.
